The molecular adsorbent recirculating system as a liver support system: summary of Mexican experience.

AIM: The aim of this study was to assess the effects of the molecular absorbent recirculating system (MARS) on patients with acute liver failure (ALF) and liver failure with cirrhosis (AoCLF) as well as in cholestatic patients with intractable pruritus in a Mexican population. MATERIAL AND METHODS: From August 2003 to December 2011, MARS was used in 38 patients with ALF, 15 patients with AoCLF, and 17 cholestatic patients with intractable pruritus. The patients were examined using a standard liver function test and for vital signs, presence of ascites and encephalopathy before and after each treatment. The therapeutic response, patient status, follow-up status, and need for liver transplantation were determined. RESULTS: Seventy-nine MARS procedures were performed. MARS was used for ALF in 54.3% of patients, AoCLF in 24.2%, and cholestatic disease in 21.5%. There were significant improvements in serum bilirubin (p = 0.000), aspartate aminotransferase (p = 0.000), alanine aminotransferase (p = 0.030), gamma-glytamyl transpeptidase (p = 0.044), alkaline phosphatase (p = 0.006), and encephalopathy grade (p = 0.000). Thirty-eight ALF patients were listed for emergency liver transplantation and treated with MARS; 20 of these patients died on a waiting list, 18 survived. only four underwent liver transplantation and 14 (37%) recovered without transplantation after the MARS procedure. CONCLUSION: MARS is a safe and effective procedure, especially for ALF patients. Our results suggest that MARS therapy can contribute to native liver recovery in ALF patients.

Re-treatment with highly purified nIFNα in Mexican nonresponder patients with chronic genotype 1 hepatitis C.

BACKGROUND AND AIMS: We undertook this study to evaluate the virological response to and presence of adverse events to natural interferon α (nIFNα; Multiferon®) treatment in previously nonresponsive Mexican patients chronically infected with genotype 1 hepatitis C. METHODS: Thirty-nine patients received a 4-week induction of 5 days/week of 6 MU nIFNα plus weight-based ribavirin followed by 3 MU of nIFNα three times a week for 44 weeks. The relationship between viral response and incidence of adverse events was analyzed. RESULTS: Early viral response (EVR) was age- and sex-dependent, with older male patients being less responsive. Sustained viral response (SVR) was evaluated according to: a) intention to treat analysis, b) 48-week treatment and 24-week follow-up (16 patients), and c) patients with EVR (11 patients). None of the factors was significantly different in groups a) and b); however, in group c) there was a better response with a marked viral load decline in younger patients and in patients aged 50 years and older. Five of 39 (13%) patients who completed treatment presented with an SVR. The most common adverse effect was asthenia in 27% of patients. CONCLUSIONS: nIFNα could be a useful strategy for re-treatment in chronic hepatitis C, genotype 1, in previously nonresponsive patients. Confirmation of these data in a larger population is required.

[First National Consensus on Chronic Hepatitis B]. / Primer Consenso Nacional de Hepatitis B Crónica.

This is the first time in our country that a group of experts in the field of hepatology gather to review the current status of HBV infection establishing the First National Consensus on Chronic Hepatitis B. With the new sensitive diagnostic methods, new antivirals capable of inhibiting viral replication, the appropriate use of passive and active immunoprophilaxis, and the better understanding of the natural history of the disease, we are finding new corners in the approach of high risk groups and management of infected patients. The National Consensus on Chronic Hepatitis B reunited 34 Mexican leaders in Hepatology, Gastroenterology, Infectology, Pediatrics, Oncology, Pathology and Molecular Biology. During these rounds the need of incorporating new knowledge on Hepatitis B in our daily clinical practice was analyzed in a way to transform Hepatitis B to an understandable and easy subject. Also, the fears on the knowledge of basic molecular biology, practical analysis of serologic markers, and diagnostic methodology as well as use and indications for new therapeutic agents was also discussed. This is a first consensus.

[Exploration of biliary tracts for laparoscopy for treatment of choledocholithiasis]. / Exploración de vías biliares por laparoscopia para el tratamiento de la coledocolitiasis.

BACKGROUND: Common bile duct stones are found in approximately 16% of patients undergoing laparoscopic cholecystectomy. If the diagnosis of choledocholithiasis is made in the preoperative work-up it is a common practice to refer patients to endoscopic retrograde cholangiography and endoscopic sphincterotomy. However, if the diagnosis is established during the intraoperative cholangiogram the surgeon confronts a therapeutic dilemma between laparoscopic common bile exploration, conversion to open surgery or post-operative endoscopic sphincterotomy. OBJECTIVE: We have opted to resolve the choledocholithiasis in only one session during the laparoscopic cholecystectomy, with the transcystic common bile duct exploration technique using the choledochoscope, or with laparoscopic choledochotomy. We report our early experience in terms of success of stone removal, operative time, morbidity, mortality and hospital stay. METHODS: from 1992 to 2003 we performed 460 laparoscopic cholecystectomies and using selective cholangiography in 138 patients (30%) we found 52 patients with common bile duct stones, for an incidence of 11.3%. RESULTS: Of this group we performed laparoscopic common bile duct exploration in 46 patients, and our success rate for stone removal was 95.6% (44 of 46) with only two failures related to multiple stones and impactation at the ampulla for a conversion rate of 4%. The mean operative time was 120 +/- 40 min. A morbidity of 8.6% was found, with no mortality. Hospital stay was 48 hrs. Mean recovery time was 7 days, and time to return to work 15 +/- 3 days. CONCLUSIONS: We concluded that must of the patients with common bile duct stones found during laparoscopic cholecystectomy can be treated with success using the laparoscopic technique with choledochoscopy, without increased morbidity or mortality, and with a short hospital stay and recovery time similar to patients in whom only laparoscopic cholecystectomy is perform. According to our results we encourage that this method should become the primary strategy in the great majority of patients with common bile duct stones found during intraoperative cholangiography.

Transcystic common bile duct exploration in the management of patients with choledocholithiasis.

Common bile duct stones are found in approximately 16% of patients undergoing laparoscopic cholecystectomy. If the diagnosis of choledocholithiasis is made at the preoperative workup, it is common practice to refer the patient for endoscopic retrograde cholangiography and endoscopic sphincterotomy. However, if the diagnosis is established during intraoperative cholangiography, the surgeon is confronted with a therapeutic dilemma-that is, the choice between laparoscopic common bile duct exploration, conversion to open surgery, or postoperative endoscopic sphincterotomy. We have opted to treat patients with choledocholithiasis in only one session during the laparoscopic cholecystectomy; we use the transcystic common bile duct exploration technique employing the choledochoscope. We report our early experience in terms of success of stone removal, operative time, morbidity and mortality, and length of hospital stay. From 1992 to 2002, we performed 350 laparoscopic cholecystectomies. Selective cholangiography was used in 105 patients (30%); 40 of them were found to have common bile duct stones, for an incidence of 11.4%. Among this group, we performed laparoscopic transcystic common bile duct exploration in all but six patients. Our success rate for stone removal was 94.1% (32 of 34 patients), with only two failures related to multiple stones and impaction at the ampulla, for a conversion rate of 5.8%. The mean operative time was 120+/-40 minutes. The morbidity rate was 8.8%, and there were no deaths. Length of hospital stay was 24 to 48 hours. Mean recovery time was 7 days, and time to return to work was 15+/-3 days. We concluded that most of the patients with common bile duct stones found during laparoscopic cholecystectomy could be treated successfully by means of the transcystic technique with choledochoscopy, with no increase in morbidity or mortality and a shortened hospital stay and recovery time, similar to patients who undergo only laparoscopic cholecystectomy. On the basis of our results, we recommend that this method become the primary strategy in the great majority of patients with common bile duct stones found during intraoperative cholangiography.

Enfermedad recurrente después del trasplante de higado [simposio] / Recurrences after liver transplantation [symposium]

Objetivo. Antes de la disponibilidad el trasplante hepático, el tratamiento de la enfermedad hepática terminal estuvo limitada a los esfuerzos para corregir y controlar las complicaciones asociadas con la cirrosis así como medidas para paliar, cuando ya las otras medidas habían sido empleadas. En la última década, el trasplante hepático ha sido aceptado como tratamiento efectivo para pacientes con enfermedad terminal hepática. Sin embargo, la recurrencia de la enfermedad post trasplante es común por virus B y C. No así otras enfermedades colestásicas como cirrosis biliar primaria (CBP), colangitis esclerosante primaria (CEP) y hepatitis autoinmune (HA). El carcinoma hepatocellular tiene alta recurrencia. Objetivo. Revisión de los resultados del trasplante hepático en hepatitis por virus B y C, así como de la incidencia de recurrencia en esta enfermedad, en CBP, CEP, cirrosis por alcohol y carcinoma hepatocelular. Pacientes y métodos. Se analizan los resultados de enfermedad recurrente post-trasplante hepático en diferentes centro de trasplante. Resultados. La hepatitis B recurre en el 80-90 por ciento de pacientes con trasplante hepático. Hepatitis C se encuentra del 0-30 por ciento de pacientes en varios centros y la infección del injerto se presenta en 40-45 por ciento de los pacientes un año después del trasplante. Estos datos llevan a la exclusión de pacientes con hepatitis B para trasplante en muchos centros. En los pacientes con hepatitis C debe hacerse una cuidadosa selección para trasplante. La recurrencia de CBP tiene tasa menos al 5 por ciento. Los cambios en la colangiografía en CEP pueden ocurrir después de trasplante y habitualmente son debidos a isquemia por estenosis o trombosis de la arteria hepática. Si no ha etiología isquémica, la CEP debe ser considerada como indicación de trasplante. En carcinoma hepatocelular el trasplante es controvertido en vista de la escasez de órganos. Los resultados de sobrevida del injerto libre de tumor a tres años. En cirrosis por alcohol, la sobrevida postrasplante no es diferente a la de pacientes trasplantados por otras razones. El problema incluye aspectos éticos y el dilema de trasplantar alcohólicos es difícil...

Nutrición en pacientes con enfermedades hepáticas: (primera parte) / Nutrition in chronic liver diseases

La dieta al poder ser manipulable puede de una u otra forma comprometer la función del hígado o contribuir para mantener la misma a niveles óptimos. El objetivo del presente trabajo fue revisar los recientes avances del efecto de la nutrición sobre los aspectos clínicos en enfermedades hepáticas crónicas y el uso adecuado de medidas dietéticas haciendo énfasis en los estudios que al respecto se han realizado en México. Se incluyeron informes originales en inglés y español a través de información computada (Medline) hasta 1994, además de los informes publicados en revistas nacionales sobre el aspecto nutricio en enfermedades hepáticas

Aplicaciones clínicas de los marcadores tumorales séricos en gastroenterología / Serum tumoral markers: clinical applications in gastroenterology

Se reconocen cinco usos potenciales para los marcadores tumorales séricos; en cada caso la sensibilidad y especificidad de la prueba son fundamentales. En su mayoría, los marcadores no sirven como prueba de escrutinio, a excepción de la alfa feto-proteína en hepatocarcinoma; además, se ha comprobado el valor de este marcador en el diagnóstico, en la monitorización de la respuesta al tratamiento y detección de recurrrencia, con impacto en la sobrevida. a su vez, la mayor utilidad del antígeno carcinoembrionico es la detección precoz de la recidiva tumoral en cáncer de colon. El CA 19-9 tiene un alto grado de sensibilidad y especificidad para el diagnóstico de cáncer en páncreas y puede predecir enfermedad irresecable. La relación Testosterona/dehidrotestosterona también es útil en el diagnóstico de cáncer de páncreas. No existe un marcador tumoral de utilidad para el diagnóstico de cáncer gástrico.

Pruebas de funcionamiento hepático / Liver function tests

Las pruebas de funcionamiento hepático son instrumento fundamental en el estudio de pacientes con sospecha de enfermedad hepática para precisar el diagnóstico, conocer la gravedad, establecer el pronóstico decidir la terapéutica más adecuada; existen pruebas que se clasifican en dos grandes grupos: las pruebas bioquímicas de función hepática perse y, los marcadores de afección hepatobiliar. Ninguna de ellas en forma individual cumple con estos objetivos, es necesario la integración de varias. En los últimos años, no se ha promovido el uso de pruebas ya existentes y se han innovado algunos aspectos de ellas para hacerlas más accesibles y sencillas. La tendencia actual, estimulada por los programas de trasplante hepático, es evaluar la capacidad metabólica del injerto y disponer de parámetros más cuantitativos del grado de función. La pruebas actuales permanecen como estudios muy útiles en hepatología.

Norfloxacina en el tratamiento de gastroenteritis bacteriana aguda / Norfloxazyne in the treatment of acute bacterial gastroenteritis

Se estudiaron 65 pacientes con diagnóstico de gastroenteritis bacteriana aguda, con una edad media de 31.5 años. De este grupo de pacientes se aislaron 68 cepas patógenas; 24 de E. coli enterotoxigénica, 27 de Salmonella, 12 de Shigella, y el resto bacterias gramnegativas. El 100% de los organismos aislados de heces de los pacientes con gastroenteritis fueron sensibles a norfloxacina, 88.8% a cotrimoxazol, 45.6% a ampicilina y 30.2% a tetraciclina, lo que demuestra un porcentaje importante de resistencia a estos dos últimos fármacos. Dos pacientes fueron descartados del estudio por presentar coprocultivos negativos. A cada uno se le administraron 400 mg de norfloxacina por vía bucal cada 12 horas durante cinco días. Los síntomas y signos clínicos mejoraron en forma rápida, presentando heces formadas en un tiempo promedio de 48 horas. Los exámenes de laboratorio sólo mostraron disminución de la cifra total de leucocitos en el porcentaje de neutrófilos (p < 0.001) después del tratamiento, sin llegar a leucopenia. Sólo un caso refirió dolor epigástrico durante el tratamiento, pero desapareció por sí solo al término del mismo. Hubo curación en 61 pacientes (96.8%); en dos se aisló nuevamente de las heces el mismo germen previo al tratamiento (uno fue E. coli enteroxigénica y el otro S. enteriditis). De acuerdo con los resultados obtenidos, se puede considerar que norfloxacina es un antibacteriano eficaz para el tratamiento de gastroenteritis bacteriana aguda